OBJECTIVE: The lateral and sitting positions are those most widely used toperform lumbar puncture (LP) in infants. This study sought to compare LP success rates by position. Secondary outcomes were successful on the first attempt andrates of procedural complications.METHODS: Infants aged 1 to 90 days undergoing LP in our pediatric emergencydepartment between June 1, 2012 and October 31, 2013 were randomized to 1position or the other. Successful LP was defined as collection of cerebrospinalfluid with a red blood cell count of less than 10,000 cells/mm on either of thefirst 2 attempts. Electronic medical records were reviewed for patientinformation, cerebrospinal fluid results, and procedural complications. Providerscompleted a questionnaire detailing their previous LP experience and technique.Primary results were analyzed using the intention-to-treat principle.RESULTS: We enrolled 168 infants. Of 167 with data eligible for analysis, 82(49%) were randomized to the lateral position. There was no statisticallysignificant difference in LP success rate between the lateral (77%, 63/82) andsitting (72%, 61/85) positions (difference, 5.1%; 95% confidence interval,-8.2%-18.3%). There were no significant differences in success on the first LPattempt or the rates of procedural complications.CONCLUSIONS: Among infants 1 to 90 days of age, this study found no difference inLP success between the lateral and sitting positions.

OBJECTIVE: Few trials address the use of telemedicine during pediatric transport.We believe that video conferencing has equivalent quality, connectivity, and easeof operation, can be done economically, and will improve evaluation.METHODS: Prospective randomized pilot study was used to examine video versuscellular communication between the medical command officer (MCO) and pediatrictransport team (TT) for children with moderate to severe illness undergoinginterhospital transport. Twenty-five patients were randomized to cellularcommunication, and 25 patients were randomized to video. The MCO completed aLikert scale to evaluate connection, quality, and ease of operation. Calldurations were recorded. A Likert scale to evaluate the communication mode onpatient care was completed.RESULTS: Connection and audio quality were equivalent and there were no droppedcalls. Average call duration in the phone group was 186 versus 139 seconds in thevideo group (P = 0.055). The MCO survey results were the following: 100% foundvideo intuitive, 92% felt that disposition based on phone report was difficult,80% felt that video provided better understanding of patient condition, 70% felt that video assisted disposition, and 80% believe that video should be used fortransport. The iPad system offers a significant savings when compared withconventional telemedicine.CONCLUSIONS: Video conferencing seems as easy to complete as phone withequivalent quality and connectivity. Duration of video was equivalent to phoneconferencing. Surveyed MCOs believed that video conferencing improved assessment and disposition. The iPad-based conferencing provided significant savings whencompared with conventional cart-based or robotic units. Further evaluation ofvideo conferencing during interhospital transport is warranted.

Author information: (1)From the Departments of *Radiology, and †Pediatrics, ‡Seattle Children's;§University of Washington School of Medicine; and ∥Harborview Hospital,University of Washington School of Medicine, Seattle, WA.

OBJECTIVES: Skull fractures can be difficult to recognize on radiographs andaxial computed tomography (CT) bone windows. Missed findings may delay abusediagnosis. The role of three-dimensional (3-D) reconstructions in child abuseevaluations was retrospectively evaluated.METHODS: Twelve exemplary cases between August 2006 and July 2009 are described. All, except 2 medical-legal cases, were clinical abuse consultations. With theuse of a 1-to-3 scale, ease and accuracy of interpretation of findings betweenplain films, bone windows, and 3-D CT images were independently assessed by 2radiologists.RESULTS: In 7 cases, skull fractures were missed on initial review of skull filmsand/or bone windows. Three children sustained additional abusive injury before3-D CT reconstructions demonstrated subtle skull fractures, though imaged, weremissed on initial readings. Three children with initially unrecognized fractures had timely 3-D reconstructions confirming fractures, allowing protectiveintervention before additional injury. An unrecognized ping-pong fracture wasdiscovered on 3-D reconstructions with an inflicted subdural hemorrhage, definingthe injury as an impact. Two 3-Ds demonstrated communication of biparietalfractures along the sagittal suture. This changed interpretation to single,rather than 2 separate, concerning impacts. Three potential skull fractures were found to represent large sutural bones. In all cases, ease and accuracy ofinterpretation scores were highest for 3-D CT.CONCLUSIONS: Without increasing patient radiation exposure, 3-D CTreconstructions may reveal previously unrecognized skull fractures, potentiallyallowing abuse diagnosis before additional injury. They may clarify normal skull variants and affirm accidental injury causes. We now routinely include 3-Dreconstructions on cranial CTs for children younger than 3 years.

AIM: This study aimed to analyze the effect of isotonic versus hypotonic solutionas intravenous maintenance fluid on level of plasma sodium in hospitalizedchildren.METHODS: A fully recursive literature search in May 2013 was conducted in PubMed and EMBASE to identify potentially relevant randomized controlled trials. Jadadscore and allocation concealment were adopted to evaluate the methodologicalquality of each trial. RevMan5.2 was used for statistical analysis.RESULTS: Eight randomized controlled trials with 752 patients were included.Combined analysis showed a significant lower risk of hyponatremia with isotonicsolution (odds ratio, 0.36; 95% confidence interval, 0.26-0.51). The isotonicintravenous maintenance did not increase the possibility of hypernatremia (oddsratio, 0.86; 95% confidence interval, 0.36-2.06).CONCLUSIONS: The meta-analysis revealed that there was potential risk ofhyponatremia for routine infusion of hypotonic maintenance fluid. The use ofisotonic solution was warranted in hospitalized pediatric patients.